Patient groups questioned how the health service would cope with the up-front cost, potentially running into billions of pounds, at a time when waiting lists for treatment have topped three million, the highest for six years. …

Weight-loss operations cost about £5,000 each, but Nice said that this had to be set against the 10 per cent of the £110 billion health budget being spent on treating diabetes and its complications, which can include blindness and amputations. …

However, Tam Fry, of the National Obesity Forum, said: “There is a mismatch between what Nice says based on the clinical evidence and the fact that all of this has to be paid for in an NHS which is already in the red . . . It’s the next patient who desperately needs an operation that really feels it when the doctor says, ‘We’ve just spent our last pound’. Somebody is going to suffer somewhere.”In draft guidance to be published today, Nice said it would be cost-effective to consider weight-loss surgery to all obese people who have been given a diagnosis of type 2 diabetes within the past decade. The fattest patients should be automatically offered an assessment for surgery, while doctors must at least consider it for the rest, Nice says.

Simon O’Neill of Diabetes UK agreed that surgery could lead to “dramatic weight loss” but warned that it should not be seen as a cure or an easy option, urging patients to persist with eating better and exercising more.

COMMENTS: 23

I don’t understand the logic here. Surgery to artificially induce weight loss isn’t going to change the underlying metabolic disorder causing type 2 diabetes, is it? Won’t these people just be thinner diabetics? Possibly better off for the weight loss, possibly worse off because they can no longer eat normal quantities of food so they may not be able to control their blood sugar as well?

There’s been good research on this. Major weight loss in people with diabetes can result in normal or near-normal blood sugar.

I think this only works if you actually lose the weight by eating less and exercising more (even if the way that you go about this is surgery on your stomach). I don’t think that just surgically removing fat works, even though that produces instant weight loss.

Surprisingly, it is common for gastric bypass to reverse diabetes and the metabolic syndrome, in a way that is not well understood but seems to be somewhat independent of weight loss. It’s unfortunate that we have come to this, but the failure rate of diet and exercise in the obese is nearly 100% in the long term, and surgery seems to be the only effective therapy we’ve found to date.

I think you have your numbers – well, not exactly wrong, but stated in a misleading way. Diet & exercise always fail in the obese, because if they’re used properly, the person will no longer be obese. Conversely, if they fail to be used, the person remains obese. It’s like expecting an antibiotic to cure an infection if you never swallow the pills.

Just went through this kind of surgery through a similar experimental program.
I am very heavy but not diabetic. I might develop it later.
I never would have considered it due to the cost otherwise.
There are also other issues (likely with me) such as the need for knee and hip replacement,
foot issues and breathing difficulties.

At first glance, it appears that this surgery is treating the symptoms and not the root problem of eating unhealthy and not exercising. I don’t know much about the surgery, but if it does force people to not eat as much, then it is probably going to be much more effective than a non surgical diet at causing lasting weight management. The fact that it is free is definitely an added initial incentive, but longterm it leaves the person less invested. The fact that it is an evasive surgery does however strengthen the long term investment to stick with it. It still doesn’t address the more basic underlying problems of health education and self discipline that are the real root causes of many of these diseases of excess. All that being said, it sounds like the best band-aid for the problem that I’ve heard so far.

I have to say that I am forever disappointed by your coverage of the topic of obesity. With regards to the current post, I have found no literature that supports the view that weight loss surgery has long-term benefits. When the industry defines “success” as a 10% loss of initial body weight, data should be dissected carefully. A 300-pounder person is a successful surgery candidate if they lose 30 pounds; yet they may remain in the “morbidly obese” BMI category.

I love Freakonomics for its systematic use of data; in the case of obesity, however, your usual standards do not seem to hold. Before repeating non-sense, I invite you to take a closer look at the data. And if you find an unbiased study that suggests positive outcomes for a cohort of obese individuals 10 years out of surgery, please send it my way. It’s been elusive for almost five years.

“With regards to the current post, I have found no literature that supports the view that weight loss surgery has long-term benefits. When the industry defines “success” as a 10% loss of initial body weight, data should be dissected carefully ”

NICE isn’t industry. I suggest you inform yourself on a topic before engaging in a rant.

“I love Freakonomics for its systematic use of data; in the case of obesity, however, your usual standards do not seem to hold. Before repeating non-sense, I invite you to take a closer look at the data. And if you find an unbiased study that suggests positive outcomes for a cohort of obese individuals 10 years out of surgery, please send it my way. It’s been elusive for almost five years.”

I suggest you read the pertinent NICE report. They are all available online, if I remember correctly.

Well said. And this is true of virtually all who do or a thought to take any kind of alternative viewpoint. They always become ‘obesity’ construct drones the moment they get to discussing weight. It’s because we are all taught the same theology of weight.

Wow – an interesting but certainly double-edged idea. Bariatric surgery is a tool but not a magic bullet. The person having surgery must be invested in their own health and improvement or they may be at risk for complications, vitamin deficiencies, etc down the line. I might even wonder if in some ways the complex process for insurance approval etc makes people more invested.

For Elise – You’re right – there aren’t many long-term data in the US, most of our data show pretty interesting and promising results for 1- 2- or maybe 5- years, but there are tons of data from abroad! I would encourage you to look for the Swedish Obesity study. Though it’s not randomized (some of the newer US-produced data are actually randomized), the Swedish study has data going out for 10- 15- even up to 20-years depending on the article you find. Take a look at a couple of abstracts – http://www.ncbi.nlm.nih.gov/pubmed/23163728 this review shows statistically significant increases in diabetes remission at 2 years and also at 10 years out. There are a number of additional articles from reputable sources as well – New England Journal, JAMA, etc.

I also wonder if the “cost” given includes all the costs. The pre-surgery testing alone could run 5,000£.

Typical requirements in the US include letters from a psychotherapist, a cardiologist, a pulmonologist, and a dietician. Then you need a CT scan, an abdominal ultrasound, a colonoscopy, heart testing, and blood tests. And after the surgery, you need months of follow-up. And it really only works if you follow the diet, which isn’t expensive, but requires time, energy, and attention.

I’m afraid to say that this is probably more to do with the fact that the healthcare system in the US is so far removed from being affordable and efficient that a medical procedure near the 5 digit range (8549 dollars by today’s exchange) for… well anything… you think this is too cheap.

I really don’t think anyone in their right mind can make a decent economical argument about healthcare affordability and then go base it on US data… its just not how the world works (other than the US).

I think you are making a major conceptual error in your cost comparison. Unless doctors, nurses, other staff and medical equipment suppliers are paid significantly less in other countries than in the US, the actual COST of the procedure is going to be about the same. It’s just that in the US, that cost is paid by patients and/or their insurance companies, while in the rest of the world much of it is borne by taxpayers.

BECAUSE these procedures are paid by the taxpayer in the UK and the NHS is thus the sole buyer – or practically so – they can negotiate much more reduced prices for anything from consumables to ultrasound to CTs.

Isn’t Freakonomics supposed to be the place where thinking about unintended consequences is cool? Why suddenly chuck this thinking out the window?

If we lower the cost of getting so fat you get diabetes with “free” lap band surgeries (i.e. intrusive surgery & hospital stay, subsidized by those who work and pay taxes), should we expect to see more or fewer people sitting around eating tasty, unhealthy food until they look like hippos?

And what about those productive people who do the subsidizing? Doesn’t it eventually become a better deal for them to shrug off the yoke and go sit in the carriage–especially after we pile on some more expensive procedures that have been tenuously found to reverse the symptoms of certain consumption-related conditions?

I don’t think there would be much of an increase, due to a bunch of unexamined assumptions, like the assumption that healthy food is less tasty. From my own experience, I have to say that this just ain’t so.

Then there’s the assumption that everyone would prefer to just sit around and not exercise. Again, just not so: some don’t exercise, others exercise for the health/appearance benefits, and still others exercise because they enjoy it. (In fact, I’ve been quietly going nuts this past week because a broken toe has kept me from my usual hiking & biking.)

Seems to me that there won’t be a whole lot of progress made on these fronts until someone actually figures out why people have the preferences that they do/

I’m with you: I think the tastiest food is often the best for you, and I exercise for enjoyment, health, and appearance. Not only that, but healthy food is in many cases objectively less expensive than unhealthy food.

So why then are so many people fat and lazy and dying of obesity-related diseases? It’s true we haven’t figured out all the reasons, but we have figured out many of them.

For example, junk food manufacturers have what they do down to a science. I think it was even in a Freakonomics podcast that I learned about how they try to make food that dissolves in the eater’s mouth, triggering in his brain the illusion he is not getting any calories, making him hungrier.

Meanwhile I don’t believe exercise has gotten any less popular, but rather, the natural exercise people used to get as a matter of necessity throughout their day has greatly diminished thanks to modern conveniences inside the home and car-oriented civil engineering outside the home, as well as the increasingly sedentary nature of our jobs.

“If we lower the cost of getting so fat you get diabetes with “free” lap band surgeries (i.e. intrusive surgery & hospital stay, subsidized by those who work and pay taxes), should we expect to see more or fewer people sitting around eating tasty, unhealthy food until they look like hippos?”

Lower the cost?

I suggest you read up a bit on what having surgery means. You assume that people say “Hey, if something happens, I’ll just have surgery” . The number of people in the world who think that way is probably quite limited.

“And what about those productive people who do the subsidizing? Doesn’t it eventually become a better deal for them to shrug off the yoke and go sit in the carriage–especially after we pile on some more expensive procedures that have been tenuously found to reverse the symptoms of certain consumption-related conditions?”

Inabout as much as they would concider giving all cancer patients a coup the grace and euthanizing anyone with a genetic defect.

Just because you only think of financial costs doesn’t mean the rest of the world does.

Sensationalist headline as usual. Surgical intervention has always been a treatment option for those with a BMI >35 and a comorbidity such as type 2 diabetes. The only change is that this option will now be extended to those with a BMI 30-35 and a diagnosis within the past 10 years. This subset is not “up to a million people,” as the news article suggests. This number was calculated by a misguided journalist who counted all the recently diagnosed type 2 diabetes patients with BMI >30 (rather than BMI 30-35). A generous estimate would be about 400,000 additional cases that are considered for bariatric surgery. The choice of whether to receive the surgery would still be up to the patient, hopefully after being given a proper explanation of the risks and benefits of the procedure by his or her primary care physician.